1
" As your Daily Planner assumes its place among your “tools of daily life” (i.e., keys, cell phone, wallet, purse, etc.), you will use it to schedule upcoming commitments, such as social events, exams, meetings, appointments, etc. as they arise. In addition to organizing your day, the time spent thinking about and planning your activities is a “priming” activity that increases the likelihood of behavioral follow-through. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
2
" There are a series of philosophical problems known as Zeno’s paradoxes. One of them says that as you attempt to leave a room, you must first reach the midpoint between you and the exit. As you continue toward the doorway, you will again reach the new midpoint, with each successive attempt to exit the room requiring you to reach the next midpoint. The paradox is that you should be unable to leave a room because you can infinitely halve the distance to the exit without ever getting out of the room.
You may often feel like you are the person trying to leave the room when facing tasks on your Daily To-Do List inasmuch as it seems as though you can never get them started. We use the Zeno’s paradox example to illustrate that most tasks you will encounter can be broken down into ever-smaller component steps. More importantly, taking the right first step on a task gives you the sense that “I can do this,” a seemingly small matter that holds big rewards.
When setting out your priority tasks, you will encounter some undertakings that activate a sense of dread, an overwhelmed feeling, or thoughts that you cannot deal with them. Rather than automatically avoiding them (“I can’t handle this now!”), the first step is to consider what you want to accomplish and if your task, at least as you currently think of it, is too big or vague. The overall objective is still important, such as “organize my room” or “work on paper for school,” but framed in such broad terms it is hard to picture a way to get started. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
4
" Despite the previously mentioned strategies, you may still find yourself having difficulties getting started on tasks. The sorts of tasks on which you continue to procrastinate are likely those for which you view even these small steps as being somewhat boring or painful, such as various chores, academic tasks (e.g., reading textbooks, writing assignments), or administrative tasks of adult life (e.g., dealing with taxes, finances).
These and other tasks trigger negative thoughts and feelings for you that also interfere with follow-through, even on initial steps. A way to get started on these tasks is to define in strict, behavioral steps the smallest behaviors that are required to start the task. These initial behaviors may not involve actually completing the task, but they are necessary steps and help you to “touch” a task rather than keeping it at arm’s length.
This approach is meant to help you break down tasks into their strict behavioral steps, akin to a recipe for cooking. You may say, “I do not know how to cook” or “I cannot do it.” However, once you follow the specific steps, including “get saucepan out of cupboard,” “fill with water,” etc., you are now engaged in the task rather than being cognitively, emotionally, and behaviorally removed from it. It is an interesting exercise to see how other tasks that are typically avoided can be broken down into steps, such as a phone call (“pick up phone receiver, enter the nine-digit phone number, wait for answer, converse in my native language . . .”) or going to the gym (“stand up, go to room and find workout clothes, put in gym bag, . . .”). "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
5
" An important point to remember is that you still may not be “in the mood” to perform the task or action. In fact, remember that you may overestimate how little energy, focus, etc. is actually required to start a task. The final push to start a task or action is similar to legislative “swing votes”—it need not be a unanimous decision; you simply need to get to a 51–49 result to take the first step of behavioral engagement. As most people proclaim, “Once I got started, it was not as bad as I thought it would be.”
Once you get engaged in the task, by definition, you are no longer procrastinating and the likelihood of persistence increases exponentially. This good start does not mean that you are immune to interruptions, distractions, or frustrations, but it is an important step to move from the anticipations of a task to engaging in the reality of the task. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
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" The first step in dealing with negative automatic thoughts about a task or plan is to catch them by asking, “What am I thinking right now?” These thoughts often do not occur in the form of grammatically correct sentences, but may be expressed in brief phrases (e.g., “Oh no,” “I hate this stuff,” a string of expletives, etc.). In fact, sometimes procrastination starts with an accurate statement (e.g., “The gym is crowded after work.”), but that can kick off a string of assumptions that result in procrastination (e.g., “I won’t be able to find any open machines. It will either take me 3 hours to finish my workout or I won’t be able to do my full workout. I’m tired and I’m not up to dealing with crowds tonight. There is no use in going to the gym.”). The subsequent evening spent watching lousy television shows while eating way too many cheese puffs leads to self-critical thoughts and frustration with the missed workout (e.g., “I could have gone to the gym. I would have been done by now. Now I have to find time to make up this workout.”).
At the outset, it is vital to be aware of how your thoughts make you prone to procrastinate. Automatic thoughts are often distorted and impact your feelings about tasks. Hence, you start to psych yourself out of doing something without having a chance to get started on it, which increases the likelihood of resorting to avoiding the task through an escape behavior.
In Chapter 7, we will discuss in greater detail some of the distorted thoughts and strategies for modifying them, particularly with regard to the emotions they trigger, including pure and simple discomfort about a task (i.e., “Ugh”). When dealing with procrastination, however, the most common distortion we encounter is magnification/minimization. That is, you pull out and embellish all the negative elements about performing a task and you overlook or play down the positive elements and your ability to handle the task in question. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
7
" You will invariably face jobs that are associated with uncomfortable feelings, ranging from relatively minor annoyance (e.g., taking out the garbage in the rain) to more persistent and recurring feelings of stress and discomfort (e.g., dissertation, organizing income taxes) that activate your procrastination script. Even a minimal degree of stress or inconvenience (what we have come to describe as the feeling of “Ugh”) can be potent enough to make you delay action.
Think about some of the mundane examples of procrastination, such as watching a boring television show because the remote control is out of reach (e.g., “It’s ALL THE WAY over there.”) or exercise (e.g., “I’m TOO TIRED to change into my workout clothes.”). The use of capital letters is meant to illustrate the tone of voice of your selftalk, which serves to exaggerate and convince you of the difficulty of what you want to do. You are capable to perform the action, but your thoughts and feelings (including feeling tired or “low energy”) makes you conclude that you are not at your best and therefore cannot and will not follow through (for seemingly justifiable reasons).
You might think, “I have to be in the mood to do some things.” But, how often are any of us in the mood to do many of the tasks on which we end up procrastinating? The very fact that we have to plan them indicates that these tasks require some targeted planning and effort. When facing emotional discomfort, ADHD adults are particularly at risk for bolting to pleasant, easy, and yet often unsatisfying activities, such as eating junk food, watching television, social networking, surfing the Internet, etc.
In fact, sometimes you may escape from stressful tasks by performing other, lower priority errands or chores. Thus, you rationalize violating your high-priority project plan in order to run out to fill your car with gas. This strategy can be seen as a form of “plea bargaining”—“I will do something productive in order to justify not doing the higher priority but less appealing task.” Moreover, these errands are often more discrete and time limited than the task you are putting off (i.e., “If I start mowing the lawn now, I will be done in 1 hour. I don’t know how long taxes will take me.”), which is often their appeal—even though they are low priority, you are more confident you will get them done.
You need not be “in the mood” for a task in order to perform it. A useful reframe is the reminder that you have “enough” energy to get started and recall that once you get started on the first step, you usually feel better and more engaged. Breaking the task down into its discrete steps and setting an end time help you to reframe the plan (e.g., “I’m tired, but I have enough energy to do this task for 15 minutes.”). Rather than setting up the unrealistic expectation that you must be stress-free and 100% energized before you can do tasks, the notion of acceptance of discomfort is a useful mindset to adopt and practice. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
8
" The topic of motivation often comes up when dealing with the issue of follow-through on plans. Many adults with ADHD may aspire to achieve a goal (e.g., exercise) or get through an unavoidable obligation (e.g., exam, paying bills), but fall prey to an apparent lack of motivation, despite their best intentions. This situation reminds us of a quote attributed to the late fitness expert, Jack LaLanne, who at the age of 93 was quoted as saying, “I’m feeling great and I still have sex almost every day. Almost on Monday, almost on Tuesday . . .”
Returning to the executive dysfunction view of ADHD, motivation is defined as the ability to generate an emotion about a task that promotes follow-through in the absence of immediate reward or consequence (and often in the face of some degree of discomfort in the short-term). Said differently, motivation is the ability to make yourself “feel like” doing the task when there is no pressing reason to do so. Thus, you will have to find a way to make yourself feel like exercising before you achieve the results you desire or feel like studying for a midterm exam that is still several days away. You “know” logically that these are good ideas, but it is negative feelings (including boredom) or lack of feelings about a task that undercut your attempts to get started. In fact, one of the common thinking errors exhibited by adults with ADHD when procrastinating is the magnification of emotional discomfort associated with starting a task usually coupled with a minimization of the positive feelings associated with it.
Adults with ADHD experience the double whammy of having greater difficulty generating positive emotions (i.e., motivation) needed to get engaged in tasks and greater difficulty inhibiting the allure of more immediate distractions, including those that provide an escape from discomfort. In fairness, from a developmental standpoint, adults with ADHD have often experienced more than their fair share of frustrations and setbacks with regard to many important aspects of their lives. Hence, our experience has been that various life responsibilities and duties have become associated with a degree of stress and little perceived reward, which magnifies the motivational challenges already faced by ADHD adults.
We have adopted the metaphor of food poisoning to illustrate how one’s learning history due to ADHD creates barriers to the pursuit of valued personal goals. Food poisoning involves ingesting some sort of tainted food. It is an adaptive response that your brain and digestive system notice the presence of a toxin in the body and react with feelings of nausea and rapid expulsion of said toxin through diarrhea, vomiting, or both. Even after you have fully recuperated and have figured out that you had food poisoning, the next time you encounter that same food item, even before it reaches your lips, the sight and smell of the food will reactivate protective feelings of nausea due to the previous association of the stimulus (i.e., the food) with illness and discomfort. You can make all the intellectual arguments about your safety, and obtain assurances that the food is untainted, but your body will have this initial aversive reaction, regardless. It takes progressive exposure to untainted morsels of the food (sometimes mixing it in with “safe” food, in extreme cases) in order to break the food poisoning association.
Similarly, in the course of your efforts to establish and maintain good habits for managing ADHD, you will encounter some tasks that elicit discomfort despite knowing the value of the task at hand. Therefore, it is essential to be able to manufacture motivation, just enough of it, in order to be able to shift out of avoidance and to take a “taste” of the task that you are delaying. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
9
" Time management also involves energy management. Sometimes the rationalization for procrastination is wrapped up in the form of the statement “I’m not up to this,” which reflects the fact you feel tired, stressed, or some other uncomfortable state. Consequently, you conclude that you do not have the requisite energy for a task, which is likely combined with a distorted justification for putting it off (e.g., “I have to be at my best or else I will be unable to do it.”).
Similar to reframing time, it is helpful to respond to the “I’m not up to this” reaction by reframing energy. Thinking through the actual behavioral and energy requirements of a job challenges the initial and often distorted reasoning with a more realistic view. Remember, you only need “enough” energy to start the task. Consequently, being “too tired” to unload the dishwasher or put in a load of laundry can be reframed to see these tasks as requiring only a low level of energy and focus.
This sort of reframing can be used to address automatic thoughts about energy on tasks that require a little more get-up-and-go. For example, it is common for people to be on the fence about exercising because of the thought “I’m too tired to exercise.” That assumption can be redirected to consider the energy required for the smaller steps involved in the “exercise script” that serve as the “launch sequence” for getting to the gym (e.g., “Are you too tired to stand up and get your workout clothes? Carry them to the car?” etc.). You can also ask yourself if you have ever seen people at the gym who are slumped over the exercise machines because they ran out of energy from trying to exert themselves when “too tired.” Instead, you can draw on past experience that you will end up feeling better and more energized after exercise; in fact, you will sleep better, be more rested, and have the positive outcome of keeping up with your exercise plan. If nothing else, going through this process rather than giving into the impulse to avoid makes it more likely that you will make a reasoned decision rather than an impulsive one about the task.
A separate energy management issue relevant to keeping plans going is your ability to maintain energy (and thereby your effort) over longer courses of time. Managing ADHD is an endurance sport. It is said that good soccer players find their rest on the field in order to be able to play the full 90 minutes of a game. Similarly, you will have to manage your pace and exertion throughout the day. That is, the choreography of different tasks and obligations in your Daily Planner affects your energy. It is important to engage in self-care throughout your day, including adequate sleep, time for meals, and downtime and recreational activities in order to recharge your battery. Even when sequencing tasks at work, you can follow up a difficult task, such as working on a report, with more administrative tasks, such as responding to e-mails or phone calls that do not require as much mental energy or at least represent a shift to a different mode. Similarly, at home you may take care of various chores earlier in the evening and spend the remaining time relaxing.
A useful reminder is that there are ways to make some chores more tolerable, if not enjoyable, by linking them with preferred activities for which you have more motivation. Folding laundry while watching television, or doing yard work or household chores while listening to music on an iPod are examples of coupling obligations with pleasurable activities. Moreover, these pleasant experiences combined with task completion will likely be rewarding and energizing. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
11
" Adults with ADHD as a group have often experienced more than their fair share of disappointments and frustrations associated with the symptoms of ADHD, in many cases not realizing the impact of ADHD has had on them. When you reflect on a history of low grades, forgetting or not keeping promises made to others, repeated exhortations from others about your unfulfilled potential and the need to work harder, you may be left with a self-view that “I’m not good enough,” “I’m lazy,” or “I cannot expect much from myself and neither can anyone else.” The end result of these repeated frustrations can be the erosion of your sense of self, what is often called low self-esteem.
These deep-seated, enduring self-views, or “core beliefs” about who you are can be thought of as a lens through which you see yourself, the world, and your place in the world. Adverse developmental experiences associated with ADHD may unfairly color your lens and result in a skewed pessimistic view of yourself, at least in some situations. When facing situations in the here-and-now that activate these negative beliefs, you experience strong emotions, negative thoughts, and a propensity to fall into self-defeating behaviors, most often resignation and escape. These core beliefs might only be activated in limited, specific situations for some people with ADHD; in other cases, these beliefs color one’s perception in most situations. It should be noted that many adults with ADHD, despite feeling flummoxed by their symptoms in many situations, possess a healthy self-view, though there may be many situations that briefly shake their confidence.
These core beliefs or “schema” develop over the course of time from childhood through adulthood and reflect our efforts to figure out the “rules for life” (Beck, 1976; Young & Klosko, 1994). They can be thought of as mental categories that let us impose order on the world and make sense of it. Thus, as we grow up and face different situations, people, and challenges, we make sense of our situations and relationships and learn the rubrics for how the world works.
The capacity to form schemas and to organize experience in this way is very adaptive. For the most part, these processes help us figure out, adapt to, and navigate through different situations encountered in life. In some cases, people develop beliefs and strategies that help them get through unusually difficult life circumstances, what are sometimes called survival strategies. These old strategies may be left behind as people settle into new, healthier settings and adopt and rely on “healthy rules.” In other cases, however, maladaptive beliefs persist, are not adjusted by later experiences (or difficult circumstances persist), and these schema interfere with efforts to thrive in adulthood.
In our work with ADHD adults, particularly for those who were undiagnosed in childhood, we have heard accounts of negative labels or hurtful attributions affixed to past problems that become internalized, toughened, and have had a lasting impact. In many cases, however, many ADHD adults report that they arrived at negative conclusions about themselves based on their experiences (e.g., “None of my friends had to go to summer school.”). Negative schema may lay dormant, akin to a hibernating bear, but are easily reactivated in adulthood when facing similar gaffes or difficulties, including when there is even a hint of possible disappointment or failure. The function of these beliefs is self-protective—shock me once, shame on you; shock me twice, shame on me. However, these maladaptive beliefs insidiously trigger self-defeating behaviors that represent an attempt to cope with situations, but that end up worsening the problem and thereby strengthening the negative belief in a vicious, self-fulfilling cycle. Returning to the invisible fences metaphor, these beliefs keep you stuck in a yard that is too confining in order to avoid possible “shocks. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
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" In his book-length review of the executive functions, Dr. Russell Barkley (2012) explored the reasons that these skills evolved in humans in the first place. He makes the compelling case that it was the selection pressures associated with humans living in larger groups of genetically unrelated individuals, which made it selectively advantageous to have good self-regulation skills. That is, these abilities became more important to survival as humans became more interdependent with and reliant on dealings with people
who were not family.
Attention-Deficit/Hyperactivity Disorder (ADHD) and executive dysfunction continue to have effects on the myriad relationships and social interactions in daily life. These connections include romantic and committed relationships/marriage, relationships with parents, siblings, children, and other relatives, friendships, and interactions with employers, coworkers, and customers. The executive functions in relationships also figure in the capacity for empathy and tracking social debt, that is, the balance of favors you owe others and favors owed to you. The ability to effectively organize behavior across time in goal-directed activities gains you “social collateral.” That is, the more you deliver on promises and projects, the more that you will be sought out by others and maintain bonds with them.
Some of the common manifestations of ADHD and executive dysfunction that may create problems in relationships include:
• Distractibility during conversations
• Forgetfulness about matters relevant to another person
• Verbal impulsivity—talking over someone else
• Verbal impulsivity—saying the “wrong thing”
• Breaking promises (acts of commission, e.g., making an expensive purchase despite
agreeing to stay within a household budget)
• Poor follow-through on promises (acts of omission, e.g., forget to pick up dry
cleaning)
• Disregarding the effects of one’s behavior on others (e.g., building up excessive debt
on a shared credit card account)
• Poor frustration tolerance, anger (e.g., overreacting to children’s behavior)
• Lying to cover up mistakes
• Impulsive behaviors that reduce trust (e.g., romantic infidelity) "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
13
" …we encourage you to trust your coping plan over the long haul. It is useful to acknowledge your small and daily successes, such as facing things you would typically avoid. There will likely be daily examples of slipups, too, but, similar to looking at a garden, we encourage you to focus on the flowers as much, if not more so, than you do the weeds.
As an aside, both of us have taken up bike riding in the past few years. In our appreciation of the multiday, grand stage races in Europe, such as the Tour de France, we have seen a metaphor that helps to illustrate the goal of coping with ADHD. These multiple stage bike races last from 3 or 4 days on up to 3 weeks. Different days are spent climbing steep mountain roads, traversing long flat stages of over a hundred miles that end in all out sprints to the finish line, and individual time trials where each rider goes out alone and covers the distance as quickly as possible, known as “the race of truth.” The grand champion of a multiday race, however, is the rider whose cumulative time for all the stages is the fastest. That is, if you ride well enough, day-in and day-out, you will be a champion even though you may not be the first rider to cross the finish line on any single day’s race.
Similarly, managing ADHD is an endurance sport. You need not cope perfectly all day, every day. The goal is to make progress, cope well enough, handle setbacks without giving up, and over time you will recognize your victory.
Just keep pedaling. "
― , The Adult ADHD Tool Kit: Using CBT to Facilitate Coping Inside and Out
